OM is one of the leading causes of preventable disease amongst Aboriginal children, and has been determined by The World Health Organisation to be a serious public health issue requiring urgent attention.1-3,11 OM primarily occurs during developmental years and can drastically impact upon speech and language development, which is likely to influence educational outcomes and prospective employability- precursors to potentially life-long socioeconomic disadvantage and poverty.5
This study identifies how social determinants are addressed within grey and peer-reviewed literature, and summarises the primary determinants reported to be associated with OM and management recommendations within the literature. This study highlights gaps between factors reported to be associated with OM and recommended interventions within the literature. Given the significance of this gap, further research aimed at understanding social determinants associated with OM and identifying more effective management of the social determinants of OM within Aboriginal children is warranted. Furthermore, the inter-related nature of the social determinants of health is emphasised throughout this paper and helps to underline the challenge that an exclusively biomedical model poses in addressing specific aetiology.19(p73-74)
Notably, a shift in approaches to manage OM is desperately needed, in conjunction with further research to better understand the relationship between the social determinants of health and risk of OM in Aboriginal populations. This review demonstrates that there is an imbalanced research focus towards biomedical approaches in contrast to improving our understanding about how to address key social determinants contributing to high rates of OM in Aboriginal children. Using the social determinants of health framework, this review has identified significant shortcomings within the literature and the current public health management of OM in Aboriginal children. The social determinants of health framework used within this study identifies three key areas of Aboriginal health that are largely neglected by the available grey and peer-reviewed literature in relation to OM management. Although the literature mentions various social determinants that are consistent with the framework (e.g. housing, education, employment, community engagement, culture and history), none of the included articles evaluated these key areas of Aboriginal health with the objective to establish effective social, environmental, political or cultural-focussed interventions for OM. Further, the key social determinants of OM can be argued to stem from the persistent social, economic and cultural discrimination experienced by Aboriginal populations. Through evaluation using the social determinants of health framework, this review highlights the need to preserve Aboriginal culture, strengthen Aboriginal self-determination, respect and support Aboriginal connection to land, empower Aboriginal communities, improve education and employment opportunities for Aboriginal people, and address poor housing conditions and overcrowding within Aboriginal communities. Importantly, one of the most significant and achievable goals should be to ensure the adoption of co-creation and a decolonised approach to ear health research, and health research more broadly, in Aboriginal populations. Aboriginal self-determination and services that are embedded within community are key to improving the management of OM within Aboriginal populations.20 Such an approach is needed to help ensure success of public health programmes and services aimed at reducing the risk of OM in early life, and consequently helping to eliminate the cycle of disadvantage that contributes to social determinants driving ill-health across the life-course. Measurement of such targets should be done through formal and informal consultation with community at each step of the research process. There is growing acknowledgement within the literature that the current empirical research paradigm should adopt co-creation and qualitative research methods, in conjunction with quantitative methodology, to ensure successful research and research translation within Aboriginal communities.20 Furthermore, recognising Aboriginal people as experts of their communities is vital to ensure successful planning, development, implementation and evaluation of health research and health approaches within Aboriginal contexts.
The most evident theme arising from this review was the importance of the home environment, with housing-related determinants reported almost three times more than the next most frequently reported risk factor. Despite acknowledgement of the association between housing and the prevalence of OM in Aboriginal children, there were no intervention studies within the reviewed literature that investigated how to effectively address the issue of housing in Aboriginal populations. Exposure to cigarette smoke and poor hygiene were not directly acknowledged as relating to housing within this review. However, these risk factors are likely to be influenced to some degree by the home environment, given the relatively high rates of smoking within the home in Aboriginal populations.15,16 It is therefore evident, that addressing the home environment is fundamental to adequately manage OM in Aboriginal populations. Moreover, further research into housing as a determinant of OM and as a means for intervention is desperately needed, given the lack of information available to adequately deal with this area of Aboriginal health. Addressing housing issues in Aboriginal communities is a complex issue, particularly when considering the importance of connection to land in contrast with the importance of the physical structure itself. It can be said that the efforts of government housing programmes have been heavily focussed on the logistics. For example, funding and physical infrastructure, with little acknowledgement of the need to develop culturally appropriate housing policies and pathways.21(p207) Carson et al21(p219) stress the lack of intervention studies that link housing to Aboriginal health outcomes and the ability to develop policy is limited as a result. The lack of intervention studies is also highlighted by this review, as no intervention studies looking at social determinants and Aboriginal health outcomes were identified within the literature. Intervention studies are crucial for policy development and although remoteness, and political and social barriers exist for improving housing and infrastructure in Aboriginal communities,21 a shift in focus towards more culturally appropriate housing policy and provision is urgently needed.
Exposure to tobacco smoke is consistently reported as a key contributing factor for Aboriginal children developing OM. Aboriginal children who are exposed to tobacco smoke in the home and who do not attend day-care have been suggested to be at greatest risk of developing OM.18 This is not to say that home-care by parents and family is problematic. However, given the relatively high rates of smoking within the home environment,18 it is an important issue for consideration. Jacoby et al18 suggest that children who are exposed to tobacco smoke in the home who also attend day-care may be at lower risk of developing OM, presumably because the time spent at day-care means less time exposed to tobacco smoke in the home. However, day-care attendance has previously been associated with a greater risk of OM, and further research may help to explain this relationship. Moreover, this inconsistent research helps to highlight the evident gaps within the literature resulting from the long-standing narrow lens of the biomedical focus of the existing research. Furthermore, this supports calls for further investigation into the relationship of the social determinants of health and environmental factors with OM risk in Aboriginal children.
Education and employment of the primary caregiver is cited frequently as an important determinant for Aboriginal children developing OM. However, no paper within the reviewed literature discussed this any further than listing it as a significant contributing factor. It is important to highlight that low-level education and lack of employment opportunities consign many Aboriginal people to levels of poverty.22(p108) Furthermore, education that excludes culture and native language has been demonstrated to adversely impact individuals by disempowering Aboriginal communities and harming the cultural identity of these communities.21 Moreover, hearing loss associated with OM is likely to further disengage children within the classroom, and this is compounded by lack of engagement due to hearing loss being misconstrued as misbehaviour. It is therefore clear, that Aboriginal children face significant barriers within the classroom and highlights the need for culturally appropriate schooling, accompanied by approaches to reduce rates of OM and hearing loss. Notably, there were no papers identified within this review that comprehensively evaluated the impact of OM across the life-course, including the impact of OM on speech, language and early childhood development, which may impact educational outcomes and long-term social and emotional wellbeing.
Aboriginal community involvement is an area that requires greater emphasis and encouragement from public health promoters, policy makers and service providers. Programmes such as the ‘Healthy Ears, Happy Kids’,9 'Aboriginal Otitis Media Project'23, ‘Hearing, Ear Health and Language Services’ (‘HEALS’)24 and ‘Deadly Kids, Deadly Futures’25 help to draw attention from government and non-government organisations towards the seriousness of the burden of OM in Aboriginal communities. ‘HEALS’ and ‘Deadly Kids, Deadly Futures’ have helped to demonstrate priority areas for the public health management of OM in Aboriginal communities, in addition to recommendations about key research considerations when working with Aboriginal communities. Priorities include working towards improved coordination, access and delivery of services, enhancing capacity building within communities, and Aboriginal control of research activities and translation.24-25 Furthermore, these programmes have helped to educate and empower Aboriginal communities and health workers to manage OM more effectively in a culturally safe way.9,23-24 Given the historical marginalisation, neglect and subjugation of Aboriginal populations, empowering Aboriginal communities to manage health services, develop and implement research, and provide recommendations is essential to overcome issues of mistrust, and consequently, improve cultural access to essential services. Importantly, ‘Deadly Kids, Deadly Futures’, which was not identified by the systematic literature search, provides a ‘social determinants model of ear and hearing health’ that highlights relevant social determinants of ear health for Aboriginal children.25 This model may be useful to guide future research, policy development and the development of services. However, research focussing on how to best target these social determinants is lacking. Therefore, further work is needed to advance these programmes and identify how to effectively target the underlying social determinants of OM in Aboriginal children.
Despite the lack of research about how to effectively target the social determinants of OM, there is a growing body of research regarding diversifying health approaches to better address social determinants of health more broadly. The term ‘Integrated models of care’ has emerged within the literature, which describes the integration of biomedical services with non-medical community services (e.g. housing, employment and food insecurity services) to provide a more comprehensive approach to target underlying risk factors for ill-health.26 Using a similar approach, it is recommended that tools to screen for social determinants associated with OM are developed. This will assist health workers to identify and target important social, environmental and cultural risk factors associated with OM.27-28 Information obtained through this type of screening may provide health workers with relevant information to refer at-risk children to community services, in conjunction with traditional medical management, to help alleviate factors placing a child at heightened risk. This process has been referred to as ‘social prescribing’ and aims to broaden the often-narrow focus of biomedical intervention alone.28 Therefore, it is recommended that future research looks at ‘integrated models of care’ and ‘social prescribing’, and how they can be incorporated into primary care management of OM and ear disease. Additionally, service coordination is key for successful navigation of healthcare systems and referral pathways, which are often complex. By integrating a wider variety of services in the primary care of OM, such as housing or employment services, the need for coordination is particularly important to support the implementation of such models.24, 28
While this review presented a comprehensive analysis of both peer-reviewed and grey literature, this study excluded unpublished masters and doctoral theses. Despite this, findings by Vickers and Smith29 following review of the Cochrane Library, found only one of 878 systematic reviews included data from theses that could have significantly altered the conclusions of the 878 reviews. Moreover, there is limited benefit of including theses in systematic reviews, as they rarely influence the conclusions, and retrieving and analysing unpublished dissertations involves considerable time and effort.29 The timeframe of this project also limited the number of selected databases and consequently the number of papers that were included within the study. However, 50 articles still provides comprehensive scope of the literature to enable thorough analysis, detailed explanation and well supported recommendations. Using Google Scholar presented limitations in search function, as search box options within the database meant that a modified search was needed to fulfil the specified search strategy and to remain consistent with searches performed on the other selected databases.